Cauda Equina Syndrome is an uncommon condition but can severely impact a patient if misdiagnosed. It can leave the patient with permanent incontinence of both urine and faeces, and loss of function in the lower limbs.
Compounding the situation is the speed at which the condition can deteriorate.
Cauda Equina Syndromearises from a compression of the lumbar spinal canal; typically caused by a large disc herniation, epidural bleeding or infection, or a spinal tumour.
There is also a lot of mystique and misunderstanding about it. It is often taught and seen as a single symptomatic condition: an incontinent person.
In truth it is a condition that evolves, and it is important to recognise the early stages and treat before the patient deteriorates.
Unfortunately, a lot of medical professionals across the entire spectrum – GPs, hospital doctors and specialists – misdiagnose it. As a result, for an uncommon condition, Cauda Equina Syndrome is over-represented in medico-legal actions.
Early stages Cauda Equina Syndrome
The patient may not yet be incontinent. They might just retain urine or have difficulty passing urine. Accompanying symptoms may include back pain, or sciatic pain in one of both lower limbs. The onset can be abrupt or evolve steadily over a few days or weeks, with sub-acute discomfort.
But Cauda Equina Syndrome cannot be ruled out because the patient is not incontinent.
The primary initial symptom is the retention of urine, and it can escalate rapidly. If untreated, your patient could become incontinent within forty-eight to seventy-two hours.
Suspected early Cauda Equina Syndrome
It must be investigated immediately, an MRI scan taken, and then referred to a specialist or sent to the emergency department of the local hospital.
Diagnostic indicators:
- A careful patient history will reveal clues that may include some or all of:
- New onset back pain
- Sciatic pain, particularly in both lower limbs
- Patient says they are having difficulty passing urine
- Patient says their bottom is numb
2. An examination of the sphincter ani could reveal any or all of:
- Neurogical deficit of the lower limbs
- Numbness in the buttocks
- weakened contraction of the sphincter muscles.
3. An ultrasound scan might reveal retained urine in the bladder of over 200ml.
Note the following are not symptoms of cauda equina syndrome:
✘ An urgency to urinate
✘Frequency of urination
✘ Urinary dribbles.
In elderly patients a loss of bladder control may be Cauda Equina Syndrome but is commonly due to constipation arising from opioids, such as endone, or some nerve drugs.
If in doubt get an MRI, and refer your patient to a spinal specialist.
Please also view the recording of my webinar on Caudia Equina Syndrome here.
And as always if you have any questions about a patient, please feel free to call me on 02 9650 4893. I will return your call and discuss how we can help.
You can also reach me via ralphstanford@powspine.com.au.
Further Resources for Referrers include:
- Spinal Fusion surgery
- Foot Drop
- Why I only operate when it makes a difference to my patient's quality of life
- The limited role of cortisone injections for spinal conditions
- Cervical myelopathy – a disease of the spinal cord that may pass unnoticed
- Cervical Radiculopathy – shooting pains from the neck
- Back pain and how to manage it
Dr Ralph Stanford is a spinal surgeon with over 20 years’ experience. He is adept in all surgical approaches to successfully treat his patients.
As a teacher Dr Ralph Stanford is Conjoint Senior Lecturer at the UNSW; Supervisor of Training for Orthopaedic Trainees, Prince of Wales Hospital; and Education Secretary for the Spine Society of Australia.
As a researcher and scientist, he is a well-published author and Honorary Senior Scientist at Neuroscience Research Australia (NeuRA). He is also a current member of Spinal PFET.
Posted 5 September 2022
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